Treatment of recurrent VZV myelitis with intravenous immunoglobulin

Background

VZV myelitis is a rare and typically monophasic complication of VZV reactivation. There is no solid evidence for a particular treatment regimen for VZV myelitis, especially in recurrent disease. No prior reports or studies have looked at using intravenous immunoglobulin for this condition, particularly for refractory cases.

Case report

A 75-year-old female presented with paresthesia on the right lateral leg, followed by a vesicular rash in a T2 dermatomal distribution. Over a period of 2 weeks, she experienced bilateral lower extremity weakness. MRI revealed a C3-C6 enhancing lesion. VZV positivity was confirmed by skin biopsy. She was treated with 5 days of Solumedrol 1gm IV and valacyclovir 1gm TID with improvement of weakness and rash. However, over the next two years, she continued to get occasional disseminated vesicular rash with each flare of her myelitis despite continued valacyclovir. She was started on monthly IV Ig (1gm/kg IV Ig over 2 days) for her recurrent myelitis. Since starting monthly IV Ig there have been no further zoster outbreaks or episodes of myelitis. Her balance and gait have improved significantly.

Conclusion

We present an unusual case of recurrent disseminated zoster with myelitis successfully treated with monthly IV Ig. The successful treatment of this patient should prompt consideration for its use in similar cases of recurrent VZV myelitis and may provide insight for future studies on how to treat VZV-related diseases.